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Preterm labor and PROM

Preterm labor and PROM. Dr. Wisit Woranitat. Preterm labor. What is preterm labor How dose labor start What can happen if my baby is born too early What factors increase the risk of preterm labor What are the signs and symptoms of preterm labor How can preterm labor be diagnosed.

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Preterm labor and PROM

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  1. Preterm labor and PROM • Dr. Wisit Woranitat

  2. Preterm labor • What is preterm labor • How dose labor start • What can happen if my baby is born too early • What factors increase the risk of preterm labor • What are the signs and symptoms of preterm labor • How can preterm labor be diagnosed

  3. Preterm labor • If I am at risk of preterm labor, what can I do to decrease the risk • How do I monitor myself for contraction • What medications are used to slow or stop per term • What are the special needs of preterm babies

  4. What is preterm labor • The labor begin start before 37 weeks • About 1 in 10 babies born in USA • 75% of neonatal mortality • 50% of the long term neurologic impairment in children

  5. How does labor start • Regular uterine contraction • Progression of cervix • Effacement • Dilatation • Hormones produced by uterus and placenta

  6. What can happen if my baby is born too early • Newborn death • Eyes • Ears • Breathing • Nervous system

  7. Perinatal Morbidity • Pulmonary- RDS bronchopulmonary dysplasia • Cardiovascular: PDA, persistent fetal circulation • CNS: IVH, cerebral palsy, seizures, sensory deficits • GI: NEC • Metabolic: hypoglycemia, hypocalcemia, jaundice

  8. Perinatal morbidity • Infections: GBS, E. Coli • SIDS • Psychosocial:> prevalence of child abuse

  9. Pathogenesis • 80% of Preterm births are spontaneous • 50% Preterm labor • 30% Preterm premature rupture of the membranes • Pathogenic processes • Activation of the maternal or fetal hypothalamic pituitary axis • Infection • Decidual hemorrhage • Pathologic uterine distention

  10. What factors increase the risk of preterm labor

  11. What are the signs and symptoms of preterm labor

  12. How can preterm labor be diagnosed • Cervical change • Regular contraction • Ultrasonography. ( Cx length ) • Fetal fibronectin • Fetal mornitoring

  13. Biologic markers for predicting preterm birth • Cervical length measurement- many studies have confirmed an association with cervical shortening and preterm delivery. When combined with positive fetal fibronectin and length less than 2.5 cm, this is a strong predictor of preterm delivery

  14. Biologic markers for predicting preterm birth • Fetal fibronectin- need intact membranes, less than 3 cm dilated, not useful before 24 weeks or after 34 weeks 6 days • Negative fetal fibronectin gives about a 95% chance of the pregnancy continuing 14 days or more. A positive test is not as predictive.

  15. What can I do to decrease the risk of preterm labor • Early ANC • Test or investigation • Progesterone • Limited and control the risk

  16. How do I monitor myself for contraction • Monitor for sign of uterine activity • 4 times in 20 minutes • 8 times in 60 minute • Vaginal discharge • PROM

  17. What medications are used to slow or stop preterm • Tocolysis agents • Corticosteroid • Anti-biotic agent

  18. Assessment of patients in preterm labor • Labs-CBC, UA +/- culture, electrolytes • Sterile speculum exam obtaining cultures for group B strep, BV, GC, Chlamydia, obtain fetal fibronectin • Cervical length measurement • The last thing is the cervical digital exam

  19. What are the special needs of preterm babies • NICU • Breathe • Eat • Keep warm • Other health problem

  20. Premature rupture of membrane • Definition • Incidence • Diagnosis • Risk factors • Management

  21. Definition • Premature rupture of membranes (PROM) • Rupture of the chorioamnionic membrane prior to the onset of labor at any stage of gestation • Preterm premature rupture of membranes (PPROM) • PROM prior to 37-wk. gestation

  22. Incidence • PROM – 12% of all pregnancies • PROM – 8% term pregnancies • PPROM – 30% of preterm deliveries

  23. Diagnosis • History • “Gush” of fluid • Steady leakage of small amounts of fluid • Physical • Sterile vaginal speculum exam • Minimize digital examination of cervix, regardless of gestational age, to avoid risk of ascending infection/amnionitis • Assess cervical dilation and length • Obtain cervical cultures (Gonorrhea, Chlamydia) • Obtain amniotic fluid samples • Findings • Pooling of amniotic fluid in posterior vaginal fornix • Fluid per cervical os

  24. Diagnosis • Test or investigation • Nitrazine test • Fern test • Nine blue test • Ultrasound • Indigo-carmine Amnioinfusion

  25. Nitrazine test • Fluid from vaginal exam placed on strip of nitrazine paper • Paper turns blue in presence of alkaline (pH > 7.1) amniotic fluid

  26. Fern test • Fluid from vaginal exam placed on slide and allowed to dry • Amniotic fluid narrow fern vs. cervical mucus broad fern

  27. Nile blue tests • >32 wks. Fetal fat cell can discover in amniotic fluid • Strained with Nile blue sulphate. Become to red color

  28. Fetal Fibronectin (AmniSure) • Newer test • Point of Care test • Cost-up to $50 each • Sensitivity-98.7-98.9% • Specificity-87.5-100% • Awaiting further testing prior to recommendations

  29. Ultrasound • Assess amniotic fluid level and compatibility with PROM • Indigo-carmine Amnioinfusion • Ultrasound guided indigo carmine dye amnioinfusion (“Blue tap”) • Observe for passage of blue fluid from vagina

  30. Risk factor of PROM • Prior PROM or PPROM • Prior preterm delivery • Multiple gestation • Polyhydramnios • Incompetent cervix • Vaginal/Cervical Infection • Gonorrhea, Chlamydia, GBS, S. Aureus • Antepartum bleeding (threatened abortion) • Smoking • Poor nutrition

  31. Effect to mother and fetus • Feto-maternal infection • Placenta abruptio • Premature infant: 30% - 40% of premature labour is associated with premature rupture of membrane • Cord prolapse, cord compression • Poor fetal lung development and fetal compression syndrome

  32. Management PROM at term: (1) Awaiting the onset of spontaneous labor for 12-24h (2) Termination of pregnancy after 24 hours

  33. PROM before term Termination of pregnancy (1) Evidence of fetal pulmonary maturation (2) Evidence of intrauterine infection Expectant therapy Indication : (1) Evidence of fetal pulmonary immaturation (2) Without evidence of intrauterine infection Management: (1)To enhance fetal pulmonary maturation (2) Antibiotic (3) Tocolysis

  34. Management: Rationale • Antibiotics • Prolong latency period • Prophylaxis of GBS in neonate • Prevention of maternal chorioamnionitis and neonatal sepsis • Corticosteroids • Enhance fetal lung maturity • Decrease risk of RDS, IVH, and necrotizing enterocolitis • Tocolytics • Delay delivery to allow administration of corticosteroids • Controversial, randomized trials have shown no pregnancy prolongation

  35. Management: Surveillance • Maternal: Monitor for signs of infection • Temperature • Maternal heart rate • Fetal heart rate • Uterine tenderness • Contractions

  36. Management: Surveillance • Fetal: Monitor for fetal well-being • Kick counts • Nonstress tests (NST’s) • Biophysical profile (BPP) • Immediate Delivery • Intrauterine infection • Abruptio placenta • Repetitive fetal heart rate decelerations • Cord prolapse.

  37. Thank you • For your attention

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